Just A Routine Operation

Summary

In this poignant video, Martin Bromley recounts the tragic death of his wife Elaine following a routine sinus surgery gone wrong. With a background in human factors, Bromley seeks to improve healthcare practices in the UK by sharing the story of the medical missteps that led to Elaine's brain damage and eventual passing. He highlights the critical role of communication, leadership, and situational awareness in both aviation and medical fields, urging the adoption of human factors to prevent such tragedies.

Takeaways

• 😢 The story is about the tragic death of Elaine Bromley, Martin's wife, due to complications from a routine sinus surgery in 2005.
• 👨‍✈️ Martin Bromley, an airline pilot with a background in human factors, aims to make a difference in healthcare practices in the UK based on the lessons learned from his wife's death.
• 🏥 Elaine had sinus problems and was recommended for routine sinus surgery, which she underwent with seemingly no preoperative concerns.
• ⏰ The surgery went awry when Elaine's airway collapsed after being anesthetized, leading to dangerously low oxygen levels in her body.
• 🚨 A critical situation arose where Elaine was without oxygen for a significant period, resulting in severe brain damage and ultimately her death.
• 🔍 The investigation into the incident revealed that there was a breakdown in leadership, situational awareness, decision-making, communication, and assertiveness among the medical staff.
• 🤔 There was a lack of effective communication between the medical team and the nurses, who were more aware of the situation and the necessary actions.
• 🛑 The medical team continued attempts to intubate Elaine for an extended period, missing the opportunity to take alternative actions sooner.
• 🛑 The nurses were proactive in their response, attempting to communicate the availability of equipment and intensive care support, but their efforts were not acknowledged by the medical team.
• 🛫 Martin draws parallels between the human factors involved in the medical incident and those in aviation accidents, where 75% of accidents are caused by human factors.
• 🌟 The key takeaway is the importance of recognizing and addressing human factors in healthcare to prevent such tragedies and improve patient outcomes.

Q & A

Who is Martin Bromley and what is his profession?

Martin Bromley is a father of two young children, Victoria and Adam. He is an airline pilot with a background in human factors.

What happened to Elaine Bromley?

Elaine Bromley, Martin's wife, died in March 2005 as a result of complications from an attempted routine sinus surgery that went wrong.

What was the initial plan for Elaine's surgery?

The initial plan was for Elaine to undergo a routine sinus surgery under the care of an experienced anesthetist and his assistant, starting with a laryngeal mask after a thorough pre-op assessment.

What complication occurred during Elaine's anesthesia?

During anesthesia, Elaine's airway collapsed, leading to a significant drop in oxygen levels in her body, which eventually resulted in her not waking up after the surgery.

What was the situation 10 minutes into Elaine's procedure?

Ten minutes into the procedure, Elaine was experiencing a 'can't intubate, can't ventilate' emergency, with her oxygenation at 40% or lower for over six minutes, and multiple attempts to secure her airway were unsuccessful.

How did the medical team respond to the emergency?

The medical team, including three consultants and several nurses, continued attempting to intubate Elaine for an additional 15 minutes, despite the clear guidelines for the emergency situation they were facing.

What role did the nurses play during the crisis?

The nurses were generally more aware of the situation and the necessary actions. They attempted to communicate the availability of a tracheostomy set and intensive care resources, but their concerns were not acknowledged by the consultants.

What issues were identified in the medical team's response?

Issues identified included a breakdown in leadership, lack of situational awareness, poor prioritization and decision-making, and a failure in communication and assertiveness among the medical team.

How does Martin Bromley relate the incident to his experience in aviation?

Martin Bromley draws parallels between the human factors involved in the medical incident and those in aviation accidents, noting that in both fields, a significant percentage of incidents are caused by human factors.

What is Martin Bromley's goal after the incident?

Martin's goal is to share the story and lessons learned from his wife's death to effect a change in healthcare practice in the UK, particularly in the area of human factors and communication.

What is the significance of the human factors in the aviation industry?

In the aviation industry, human factors are integral to how equipment is designed, procedures are managed, and daily work is conducted, with the aim of reducing accidents caused by human error.